HomeMy WebLinkAboutApp-Permit-ComplianceNo. &&�>L-/7 , 6P 6 7 rrr 4C � cxnc i'i- it7- Gt�2�E17
FEE 65M
17 2ff COMMONWEALTH Off' MASSACHUSETTS �����'
4 . Board of Health, Y h o—J-14- , MA. 1>41 4 `^
APPLICATION FOP DISPOSAL SYSTEM CONST U TIU MIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - 0 Complete System 0 Individual Components
Location a[ 5 `1 J ,pf (et • L, . j
Owner's Name
Map/Parcel# Q d-a•i 10 —1
Address
Lot#
Telephone#
Installer's Name,
Designer's Name �t J: "
`
Address ���• �
Address
Telephone# o ..- 7 b
Telephone#
Type of Buildingi►2 s' ✓%-/ e- Lot size Esq. ft.
Dwelling - No. of Bedrooms Garbage grinder(
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow 7 Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of.Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
a Signe / -- Date %i - /G -/ 7
Inspections
No. ��r` /JC f �7•.s.3 �3
_ rr COMMONWEALM OF MASSACHUSETTS
Boa4,q f Health. MA.
FEE
a, owl aL4t Lt s
� tA
CERTIFICATE OF COMPLIANCE
Description of Work: U In4vidual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal, System;, Constructed ( ), Repaired (-)-,,�Jpgraded ( ),Abandoned ( )
at 1 2" r G r A- r-✓ `
has been installed in accordance with the p -ovisions of CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No., Z7-,.� � F, dated ' f Approved Design Flow - gpd)
Designer:
The issuance of
Inspector:
Date:
rmit shall not be construed as a guarantee that the system will function as designed.
No. =� �- ^' L�C7 �' % �� "> sr Jy �.li !✓.i t�J 1 NC J FEE:7 • 00
?-1
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, Y&iii o m+ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygr/yanted to; Construct( ) Repair( L --Upgrade( ) Abandon( } an individual sewage disposal system
at l�li�t(�� L-, as described in. the application for
Disposal System Construction Permit No. , dated
�
.Provided: Construction shall be completed within4 of the date of this per it local con '` ' ns must be met.
j �1
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesfown, MA Date I .2-•? -"/ 7Board of Health--